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2. Name*
4. Address*
6. City*
8. Contact Phone Number*
10. Type of Property*

    1. Home

    1. Business
12. Ownership*

    1. Own

    1. Rent
14. Rental Owners Name
16. Was this a Primary or Secondary home?*

    1. Primary

    1. Secondary
18. Do you have insurance?*

    1. Yes

    1. No
20. Form of Insurance (select all that apply)

    1. Home owners
    2. Flood
    3. Renters
22. Insurance company notified?*

    1. Yes

    1. No
24. Date of Damage*
    Date of Damage
26. Estimated dollar amount of damage?
28. Type of Damage*

    1. Flood

    1. Other
30. Flood (check all that apply)

    1. foundation cracking
    2. foundation bowing
    3. water seepage
    4. six or more inches of water in basement

    1. furnace or water heater damaged
    2. water on main level of home
    3. electrical outlets damaged
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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

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